Healthcare Provider Details

I. General information

NPI: 1679118806
Provider Name (Legal Business Name): NICOLLE CELESTE REYES MELENDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 AVE JESUS T PINERO STE 103
SAN JUAN PR
00921-1100
US

IV. Provider business mailing address

PASEO DR. JOSE CELSO BARBOSA
SAN JUAN PR
00921
US

V. Phone/Fax

Practice location:
  • Phone: 787-427-9211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3360
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: